Management outcomes for ruptured and unruptured aneurysms in the elderly

OBJECTIVE

In a patient older than 70 years, the decision to treat an intracranial aneurysm remains difficult whether it is ruptured or unruptured. We sought to review our institutional risks of treatment of such lesions in the context of the risks of rupture and its associated morbidity and mortality in this age group.

METHODS

One hundred twenty-nine consecutive patients aged 70 years or older, who were treated at a single institution for an intracranial aneurysm, were retrospectively reviewed. Forty patients were treated for unruptured aneurysms, and 89 patients presented after subarachnoid hemorrhage. Seven additional patients in this age group who had solely intracavernous lesions, as well as one patient with a dolichoectatic fusiform basilar lesion, were excluded. Management outcomes were assessed using a modification of the Glasgow Outcome Scale, and additional physical and functional disability was assessed using the Barthel index and the Reintegration to Normal Living index.

RESULTS

Six-month outcomes for the unruptured group were: excellent, 70%; good, 15%; fair, 5%; poor, 7.5%; and death (2.5%). Outcomes for all patients with ruptured lesions (including those not offered aggressive therapy) were: excellent, 34%; good, 9%; fair, 5.6%; poor, 3.4%; and death, 45%. Long-term follow-up was performed by questionnaire to assess physical and functional disability. Although physical disability (Barthel index) was similar among survivors, the Reintegration to Normal Living index, a global assessment of function, was significantly higher in patients with unruptured aneurysms (84.8 versus 70.1; P = 0.05), which highlights the disabling effects of hemorrhage.

CONCLUSION

On the basis of an individual treatment center's management risks, annual aneurysmal rupture rates can be estimated that justify treatment in this difficult patient population. Despite recent controversy regarding aneurysmal hemorrhage rates, we think that symptomatic unruptured aneurysms should be treated and good results can be achieved, even in older patients.

In-chair movement: validity, reliability and implications for measuring sitting discomfort

Sitting discomfort is traditionally evaluated with subjective rating scales which are referenced to an objective correlate (e.g. sitting posture) measured on a static (i.e. non-continuous) basis. Since sitting discomfort is dynamic in nature, it requires continuous, objective measurement. We therefore adapted an interface pressure mat to continuously record in-chair movement (ICM) as an indirect measurement of sitting discomfort by tracking the center of pressure (COP) at the buttock-chair interface. Here we report on two phases in the development of the COP system: laboratory validity and field reliability. In the laboratory study we confirmed system validity by simultaneously tracking ICM with the mat and a force platform (r2 > 0.80) and by comparing subjects' COP movement with their gross trunk movements (r2 > 0.86). In our field study we used the intraclass correlation coefficient to establish a data sampling (i.e. selection) protocol that was reliable. We collected ICM data on seated telecommunications Directory Assistance operators during 2 h field tests. Results showed that using a minimum sampling time of 5 min and then averaging a series of 5 min samples of ICM was more reliable than single discrete samples. Using the averaging protocol, we also showed that ICM increased significantly over 2 h and that ICM did not differ between trials.

Case report: serologic confirmation of paroxysmal cold hemoglobinuria

A child with a history of recent viral infection entered the hospital with severe anemia, hemoglobinuria, and suspected autoimmune disease. Serologic findings included a positive direct antiglobulin test and incompatible crossmatches. Extensive studies, including a Donath-Landsteiner test, confirmed paroxysmal cold hemoglobinuria. The child was transfused several times with washed red blood cells compatible by prewarm technique. Although hemolysis continued after each transfusion, he stabilized and went home 5 days after his hospital admission. He reportedly made a complete recovery.

A comparison of parallel versus perpendicular placement of retention sutures in abdominal wound closure

A new technique for placement of retention sutures is described. Twenty-five rats underwent midline laparotomy incision. The control group was closed with traditional placement of through-and-through retention sutures placed in a perpendicular direction to the wound. The experimental group was closed with retention sutures placed in a parallel direction to the wound as described below. Wound bursting strength was significantly (P less than 0.001) greater at one to five days in the experimental group compared with the control animals. In addition, inflammatory reaction and pressure necrosis were greater in the control group. It appears that parallel placement of sutures has less of a tendency to cut through tissue when subjected to the distracting forces on a midline wound.

Sidewinder retention sutures for closure of the abdominal wall

Reported herein, a technique of sutures placement that avoids certain objections to the traditional style of retention sutures is described. It is particularly useful in patients undergoing repeated laparotomy and in patients whose wounds are closed in a layered manner and who are at high risk for dehiscence.

A comparison of the teaching effectiveness of the didactic lecture and the problem-oriented small group session: a prospective study

A prospective study was designed to assess the teaching effectiveness of active learning in problem-oriented small group sessions (POSGS) compared with passive learning in didactic lectures (DL). Third-year medical students participated in a POSGS on breast disease and a standardized DL on thyroid disease (N = 23) or participated in a POSGS on thyroid disease and a DL on breast disease (N = 19). Students were tested with a multiple-choice examination (MCQ) and a highly structured oral examination (OE) administered by faculty members blinded about student group. Results of a between-within analysis of variance performed separately for breast and thyroid disease yielded significant group differences because of instructional method for thyroid disease (p = 0.003) and approached significance for breast disease (p = 0.095). Although no significant interactions were detected with percentage scores, a significant interaction between group membership and test type was noted for thyroid disease when the percentage scores were transformed to Z scores. We conclude that regardless of topic or testing method, students in POSGS tended to perform better than students in a DL and that the POSGS offers significant advantages over the DL in teaching surgery to third-year medical students.

Natural history of cholelithiasis in patients with alcoholic cirrhosis (cholelithiasis in cirrhotic patients)

To assess the natural history of cholelithiasis in patients with cirrhosis, 32 charts coded for both diseases were retrospectively reviewed. Cholecystectomy was performed in 22 patients. Only two patients met criteria for acute cholecystitis and two patients had suspected choledocholithiasis. Despite the high incidence of preoperative jaundice (32%), no common duct stones were documented. There was no operative mortality. The complication rate was 45%. In 10 patients not operated upon, two patients died of liver failure and the remaining eight patients are alive 8 months to 13 years after diagnosis (mean: 46 months) with no active biliary disease. It is concluded that: jaundice in this subpopulation most often reflects hepatocellular injury and rarely biliary tract obstruction, there appears to be a much lower incidence of acute cholecystitis and choledocholithiasis in cirrhotic patients with cholelithiasis than in the normal population, and patients with cirrhosis and asymptomatic cholelithiasis can be safely managed without operation.

Experimental pulmonary infarction in dogs: a comparison of chest radiography and computed tomography

Transcatheter electrocoagulation of the pulmonary artery was used to successfully create experimental pulmonary infarcts in 15 to 16 dogs. The animals were evaluated from one to 13 weeks by chest radiography, computed tomography (CT), angiography, and pathologic examination. The abnormal densities in the dogs' lungs cleared in two to three weeks. The majority of the chest radiographs were normal in two weeks, and all were normal after three weeks. Prior to sacrifice, CT showed abnormal densities in the lungs in only two of eight animals. CT proved to be more sensitive than chest radiography for showing the densities in the lungs due to pulmonary infarction.